What are the treatment options for chalazion and hordeolum?

Treatment of Chalazion and Hordeolum

Distinguishing Between the Two Conditions

The critical first step is accurate diagnosis, as hordeolum and chalazion require different management approaches. 1, 2

Hordeolum presents with:

• Painful, erythematous nodule at the eyelid margin 1, 3
• Rapid onset with acute inflammation 1, 3
• May have purulent discharge 3
• Often associated with bacterial blepharitis 1, 3

Chalazion presents with:

• Painless nodule within the tarsal plate 1, 2
• Gradual onset 1, 2
• Visible meibomian gland obstruction on eyelid eversion 1, 2
• Associated with meibomian gland dysfunction or chronic blepharitis 2

Treatment Algorithm for Hordeolum

First-Line Conservative Management

Warm compresses combined with topical antibiotics are the recommended first-line treatment for hordeolum, as most cases resolve spontaneously within 5-14 days. 2

• Apply warm compresses to the affected eyelid for 10-15 minutes, 3-4 times daily 2
• Gentle massage of the affected area after warm compresses helps express the obstructed gland 1
• Clean eyelid margins with mild soap or commercial eyelid cleansers 1
• Prescribe topical antibiotic drops or ointment to protect against secondary bacterial infection and treat the primary staphylococcal infection 2

When to Escalate Treatment

• Use topical antibiotics for moderate to severe cases or when signs of spreading infection are present 1
• Institute regular eyelid hygiene measures, as hordeolum is frequently associated with bacterial blepharitis 2

Evidence Quality Note

The evidence base for hordeolum treatment is notably weak, with current recommendations based primarily on expert consensus from ophthalmology guidelines rather than randomized controlled trials. 2, 4, 5 A 2017 Cochrane review found no randomized trials evaluating non-surgical interventions for acute internal hordeolum 5.

Treatment Algorithm for Chalazion

Conservative Management (First-Line)

Conservative treatment with warm compresses and eyelid hygiene should be attempted first, as many chalazia resolve spontaneously. 2, 6

• Warm compresses applied for 5-10 minutes, several times daily 1
• Eyelid margin cleaning with mild soap or commercial eyelid cleansers 1
• Gentle massage after warm compresses 1
• Hot compresses as part of conservative treatment can improve meibomian gland function at the chalazion site in the short term 6

Interventional Options for Persistent Chalazia

For chalazia that persist despite conservative management, intralesional steroid injections or surgical removal are the next steps. 1

Surgical incision and curettage remains a standard option for persistent lesions 7

Intralesional triamcinolone acetonide injection is an alternative to surgery 7

Intense pulsed light (IPL) with meibomian gland expression has shown promise as a non-surgical treatment option for recurrent multiple chalazia, though this is not covered by insurance and is relatively costly 8, 1

• IPL should be used with caution in darkly pigmented individuals (above Fitzpatrick skin type IV) due to risk of burns and pigmentation changes 8
• Retrospective reports indicate IPL with meibomian gland expression can be effective for recurrent multiple chalazia 8

Important Consideration About Meibomian Gland Loss

Chalazion causes permanent meibomian gland loss in the affected area, regardless of treatment method. 6 The range of meibomian gland loss correlates with the size of the chalazion itself, not the treatment approach 6. Conservative treatment with hot compresses can improve meibomian gland function in the short term, but does not prevent gland loss 6.

Critical Red Flags Requiring Further Evaluation

Recurrent chalazia in the same location, especially in elderly patients, raise suspicion for sebaceous carcinoma and require biopsy. 8, 1

Additional warning signs include:

• Marked asymmetry or resistance to therapy 8, 1, 3
• Unifocal recurrent chalazia that don't respond well to therapy 8, 1
• Loss of normal eyelid margin anatomy 8
• Focal lash loss (ciliary madarosis) 8, 3
• Nodular mass, ulceration, or extensive scarring 8
• Unilateral chronic blepharitis unresponsive to standard medical treatment 8, 2, 3

Before obtaining a biopsy for suspected sebaceous carcinoma, consultation with a pathologist is recommended to discuss the potential need for frozen sections and mapping of the conjunctiva to search for pagetoid spread. 8 Fresh tissue may be needed to detect lipids using special dyes such as oil red-O 8.

Prevention Strategies

Regular eyelid hygiene is essential for patients with blepharitis or meibomian gland dysfunction to prevent recurrent hordeola and chalazia. 1, 2

• Treat underlying skin conditions such as rosacea or seborrheic dermatitis 2
• Avoid eye makeup during active inflammation 2
• Use a more aggressive eyelid hygiene regimen for patients with recurrent hordeola 1
• Address moderate to severe blepharitis prior to intraocular surgery 8

Follow-Up Considerations

Patients with mild disease should return if their condition worsens, while those with planned intraocular surgery require follow-up after initiating treatment to reassess eyelid inflammation control. 8 If corticosteroid therapy is prescribed, patients should be re-evaluated within a few weeks to determine response to therapy, measure intraocular pressure, and assess treatment compliance 8.